Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Wednesday, October 15, 2008

Oh dear. I really have been negligent. Dinah has been working hard to carry on Shrink Rap single-handedly---and done a smart job of it too---while I've been frittering my time away hanging from rocks. But more about that later.

So here is my post. Late, short, but better than nothing.

So I've been hearing a lot lately that I may be rather crazy, or at least lacking in good judgment, for my newest hobby. Dinah has suggested that I could use it as the starting point for a blog post, and I think that's a good idea.

For the past couple months I've been off rock climbing. It's something I've always wanted to try but couldn't convince my friends to try with me. Unfortunately, for the kind of climbing I do you actually do need a friend to go with you to hold the end of the rope. And the friend has to be someone you trust completely. Given that Dinah refused, repeatedly, to hold the end of my rope it took me a while to try this hobby. Now that I've done it, I'm hooked.

So how does this relate to psychiatry? Wow, there are a lot of take-off points here. I could talk about the difference between intelligence and judgment. I could talk about issues related to trust and how you choose the people you trust. Or---and this is my preference---you could talk about risk-taking behaviors in general.

My prison patients are risk-takers. They grab opportunities to make a quick buck, get revenge, blow off steam or just blow up. The problem with my patients' risk-taking behavior is that it gets them into trouble with the law.

I rarely see pro-social risk-takers because they channel their proclivities in ways that are either beneficial for them or at least don't injure others. Pro-social risk takers are people who start businesses, explore new countries, try to set new world records or who 'boldly go where no man has gone before'. They are the adventurers and visionaries.

Why do these folks fall into one category versus the other? And what makes people risk-takers?

I think there are three things that interact here: inheritance or biology, environment (including things like socioeconomic status and resources) and individual life events or experience.

Risk-taking is a character or personality trait that exists in everyone across a continuum, like extroversion or neuroticism. People are more or less risk-taking and open to new experience. There's a biological basis for many personality traits, and risk taking does seem to be heritable. Risk-taking or sensation-seeking tendencies may co-exist with impulsivity, but not always. Non-impulsive risk-takers take the time to plan their risks---to take reasonable precautions or safety measures and to weigh out the odds (or in the case of rock-climbing, make sure the rope is anchored soundly) to maximize the chance of success. If you've grown up in a disadvantaged neighborhood where the school drinking fountains are laced with lead, you're more likely to be an impulsive risk-taker (or one of my patients). Thus, environmental factors can influence the way an inherited trait is expressed.

The third and final way is through life experience. You can imagine all the life-changing events that could influence risk-taking behavior---watching the market crash, for example, is probably putting a damper on some economic risk-taking right now. Similarly, someone who is given a diagnosis of a terminal illness might decide to uncharacteristically go on a round-the-world trip. You get the drift.

As far as my risk-taking is concerned, it's basically just for the fun of it. Thanks for bearing with me, my fellow Shrink Rappers.

I always thought rock climbing would be fun, but now I'm too bottom-heavy to try it.

I was a much bigger risk-taker when I was younger (teens and early twenties), which lead to some stupid behaviors (free riding galloping and jumping horses, driving 100 mph on back roads, etc.), which lead to some injuries -- and thankfully no deaths -- which lead to much more cautious behavior.

Do people in your prison population (maybe not just your patients) fail to learn from their consequences?

Do you believe there's any physiological basis to the amount of risk one is willing to take?

I know that it would be professionally unsound to try to diagnose someone just by looking at the multi-page comments they make, but I'm wondering how I can help him. Also, and it's a long shot, whether he could pose a danger to me or my son.I'm *almost* sure he's harmless, but I'm very glad he's on the other side of the planet and not next door.

A typical example of the comments by "Yosemite Sam" (as we call him)are the comments on this post on my blog, but you'll find more on nearly every other post in the last few days.

I'm used to trolls, but this one is different.

I'm wondering if my lack of hurt response is appropriate - am I exacerbating his condition? Should I pretend to be upset? He's actually quite intelligent, and has made some good points amongst the obscenities and insults, so he's an asset in that regard. But mainly, I'm concerned for him. This goes beyond trolling and into obsession.

He's looking for emotional buttons to press to cause hurt, which might suggest NPD. I can't help but be fascinated that someone is actually desperately searching for ways to distress me, and so I'm afraid I'm treating him as some form of lab rat, rather than as a fellow human being in distress. I don't want to do that, to forget his humanity.

Any thoughts as to possible courses of action? Not as medical advice, just some ideas?

Tigermom: I wanted to post some studies about risk-takers & other traits but just didn't have time. There was one article about people who do extreme sports---it suggested that risk-taking may transiently relieve anxiety for some people. That may be a followup post.

Anonymous: Yes and yes. My prisoners have trouble learning from consequences and there may be a physiological basis. Sociopaths as a whole tend to have lower autonomic reactivity so they may be less impaired by fearfulness.

Zoe: Ugh. I'm sorry. Speaking as a fellow blogger rather than as a physician, the best response is no response to trolls. As a forensic psychiatrist, I can't & wouldn't diagnose someone on a blog. In general though, people who stalk through computers are similar to people who stalk through letters/mail in that the more time they spend stalking the less likely they are to actually approach or to harm the victim.

Ugh, I just tried to leave a comment and the temporary laptop I'm using ate it. (sigh).

Anyways... Clink, welcome back. good to have you. Tigermom... I'll give you my $.02 on your question if you don't mind... From my own personal experiences, my high risk risk-taking behaviors kicked in when I was in the midst of acute manic episodes... As I matured (aged?) and was able to understand the riskiness in my behavior, I began to channel the risk taking behavior into more positive endevours (overseas travelling; my EMT work in the middle east, etc) - which also provided me with secondary benefits, not only in terms of socialization, but also in terms of my self-esteem and self-confidence.

Re: depression - perhaps one of the Shrinks can clarify, but my understanding of the DSM diagnostic criteria for depressive illness is that people who experience depression withdraw from pleasurable activity, or don't take pleasure from those things which previously made them happy... So... it would seem to me that if a person found a risk taking activity like rock climbing enjoyable and pleasurable during a period of stability, during a period of depression, they would withdraw from engaging in such an activity... What are your thoughts?

I commend you on your risk taking but fun hobby. I am not a risk taker myself...I am terribly neurotic. Takes me forever to even order a pizza...have to take a poll of what others think will be the best topping.

Is being adventurous the same as being a risk taker? Or is risk taking something that can be small, even intimate?

I have always enjoyed the big, outdoors risks - mountain climbing, scuba diving, adventure travel. Those don't feels so risky, though. It's the interpersonal stuff that often feels risky. And when I conquer an interpersonal fear, that's when I feel courageous.

I have never done technical rock climbing, though I climbed a cliff in Arizona with a 16-year old American Indian as my guide, with no ropes (he showed me exactly where to place my feet and hands).

I've also done a lot of overseas travel solo and with a partner. I started my own business. I was the first American woman to do research based at remote field site in the Transantartic Mountains, in Antarctica. I went back to school at 57 for my teaching credential. None of the latter took the kind of fearlessness that rock climbing requires though I am complimented to be included in the same category.